Inside Health

FINDINGS; To Explain Longevity Gap, Look Past Health System

By JOHN TIERNEY

Published: September 22, 2009

If you're not rich and you get sick, in which industrialized country are you likely to get the best treatment?

The conventional answer to this question has been: anywhere but the United States. With its many uninsured citizens and its relatively low life expectancy, the United States has been relegated to the bottom of international health scorecards.

But a prominent researcher, Samuel H. Preston, has taken a closer look at the growing body of international data, and he finds no evidence that America's health care system is to blame for the longevity gap between it and other industrialized countries. In fact, he concludes, the American system in many ways provides superior treatment even when uninsured Americans are included in the analysis.

''The U.S. actually does a pretty good job of identifying and treating the major diseases,'' says Dr. Preston, a demographer at the University of Pennsylvania who is among the leading experts on mortality rates from disease. ''The international comparisons don't show we're in dire straits.''

No one denies that the American system has problems, including its extraordinarily high costs and unnecessary treatments. But Dr. Preston and other researchers say that the costs aren't solely due to inefficiency. Americans pay more for health care partly because they get more thorough treatment for some diseases, and partly because they get sick more often than people in Europe and other industrialized countries.

An American's life expectancy at birth is about 78 years, which is lower than in most other affluent countries. Life expectancy is about 80 in the United Kingdom, 81 in Canada and France, and 83 in Japan, according to the World Health Organization.

This longevity gap, Dr. Preston says, is primarily due to the relatively high rates of sickness and death among middle-aged Americans, chiefly from heart disease and cancer. Many of those deaths have been attributed to the health care system, an especially convenient target for those who favor a European alternative.

But there are many more differences between Europe and the United States than just the health care system. Americans are more ethnically diverse. They eat different food. They are fatter. Perhaps most important, they used to be exceptionally heavy smokers. For four decades, until the mid-1980s, per-capita cigarette consumption was higher in the United States (particularly among women) than anywhere else in the developed world. Dr. Preston and other researchers have calculated that if deaths due to smoking were excluded, the United States would rise to the top half of the longevity rankings for developed countries.

As it is, the longevity gap starts at birth and persists through middle age, but then it eventually disappears. If you reach 80 in the United States, your life expectancy is longer than in most other developed countries. The United States is apparently doing something right for its aging population, but what?

One frequent answer has been Medicare. Its universal coverage for people over 65 has often been credited with shrinking the longevity gap between the United States and other developed countries.

But when Dr. Preston and a Penn colleague, Jessica Y. Ho, looked at mortality rates in 1965, before Medicare went into effect, they found an even more pronounced version of today's pattern: middle-aged people died much more often in the United States than in other developed countries, but the longevity gap shrunk with age even faster than today. In that pre-Medicare era, an American who reached 75 could expect to live longer than most people elsewhere.

Besides smoking, there could be lots of other reasons that Americans are especially unhealthy in middle age. But Dr. Preston says he saw no evidence for the much-quoted estimates that poor health care is responsible for more preventable deaths in the United States than in other developed countries. (Go to nytimes.com/tierneylab for details.)

For all its faults, the American system compares well by some important measures with other developed countries, as Dr. Preston and Ms. Ho enumerate. Americans are more likely to be screened for cancer, and once cancer is detected, they are more likely to survive for five years.

It's been argued that the survival rate for cancer appears longer in America merely because the disease is detected earlier, but Dr. Preston says that earlier detection can be an advantage in itself, and that Americans might also receive better treatment. He and Ms. Ho conclude that the mortality rates from breast cancer and prostate cancer have been declining significantly faster in the United States than in other industrialized countries.

Americans also do relatively well in surviving heart attacks and strokes, and some studies have found that hypertension is treated more successfully in the United States. Compared with Europeans, Americans are more likely to receive medication if they have heart disease, high cholesterol, lung disease or osteoporosis.

But even if the American system does provide more treatment for more sick people, couldn't it do something to reduce its workload?

When I brought up Dr. Preston's work to Ellen Nolte and C. Martin McKee, two prominent European critics of the American system, they suggested that he was taking too limited a view of health care. They said the system should take responsibility for preventing disease, not just treating it.

Dr. Preston acknowledges that the United States might do more to keep young and middle-aged people from getting sick, but he says it's not clear that other countries' systems are more effective.

''The U.S. has had one spectacular achievement in preventive medicine,'' he says. ''It has had the largest drop in cigarette consumption per adult of any developed country since 1985.'' If Americans keep shunning cigarettes, the longevity gap could shrink no matter what happens with the health care system.